Wednesday, July 05, 2006

Against medical advice

I was sitting in my office Monday afternoon after hours getting some paperwork done, when my cell phone goes off, "Doctor, this is the hospital switchboard, is your pager not working?" I quickly grabbed it. "There are no pages on it," I said. "Well, the ER has been looking for you for about an hour." Oh no, I was thinking to myself. I hope there wasn't anything urgent going on. So, I rushed over to the hospital which is only across the street.

"Sorry, I don't think my pager is working," I said. "I thought as much because you usually call back pretty quick," the ER doc said. "We've got a 54 year-old guy that passed out at home and brought in my his wife. I'm thinking that he probably needs to be admitted."

I go into room 10, "Hello, I'm Dr. A. What happened at home today?" "Well," the patient's wife said, "he was just at home watching TV when he stopped breathing and was out for about 30 seconds. I think his eyes may have rolled back, too, but I'm not really sure."

After a few more minutes talking, I said, "What's going to happen now is that I'm going to do some paperwork to get you admitted to the hospital." "Doc, I don't think I need to stay tonight." What! I thought to myself. "Sir, I don't think it's a good idea for you to go home." "Well, doc, I think I have it figured out. My blood sugar must have been low." As I'm looking at his 320 pound frame, I'm not thinking that LOW blood sugar was his problem.

"Here's the thing," I said, "I have no idea what happened to you today, so I recommend that you be admitted for further testing." I was hoping that I didn't have to go into 'bad cop' mode, but I felt the situation escalating quickly. More discussion back and forth occurred for the next 20 minutes.

"Ok sir," I was fed up at this point, "You certainly have the right to be discharged. All you have to do is sign a paper stating that you are leaving the hospital against medical advice, and you're free to go." "Whoa! What does that mean?" "It means that I, as your doctor, am free of all responsibilty for your medical condition. It also means that YOU are accepting of all the possible complications to your condition which include heart attack, stroke, seizure..." I listed a few more and ended with, "....and possible death." I really hate it when I sound like a lawyer.

"YOU are not going to bully me around like that," he barked at me, "All you doctors are the same, just want to scare us and run needless tests that will turn up nothing anyway." "Sir, it looks like you've made your decision. I've said what I need to say. Let me get the nurse. You can sign the paper, and you can be home in an hour."

I left the room really second guessing myself. Was I too hard on the guy? Could I have de-escalated the situation? What should I have done differently? Maybe I should go back in there and apologize for my tone.

The patient's wife then came to the nurses station to talk to me. She looked sullen with her shoulders dropped and soft voice. I finally got through to them and made them understand. I may have been a little forceful about it, but, in the long run, I think I did the right thing.

"Doc, we've got family coming in tonight. When is the nurse coming in so that we can be discharged and go home?"

I think I've got it down as to what I can get patients to do. Mostly, they take the medicines I ask them to take (we won't go into at what dose). Mostly, they pay me for their treatment. More often then not, they keep their appointments. Beyond that, I'm not sure anyone has ever done anything I've asked, though many people claim to have been effected by my words then reiterated suggestions I'm certain I've never made.

People do what they will, and they can't always be swayed by even the most convincing of arguments. Mostly, I'm glad that most days I'm dealing with their emotional/psychiatric well-being and not their risk for imminent cardiovascular death.

It's a shame you weren't even able to do help find out what was wrong--and that it is likely to happen again. Why would a patient come in and then turn around and want to go home without being cared for properly? You don't even have the chance to "do no harm" and instead have to CYA because the patient is harming himself.

Dr. A...I think you handled that the best way you could. Some folks have their minds made up and aren't going to change until they're forced to. Keep on keeping on...it sounds like you're a great doctor! Have a great day.Karen

"Just sitting at home...when he stopped breathing..." Yoiks! Well, when the rest of the family arrives perhaps one of them will have taken CPR and will be able to save dad (from what, though? sudden cardiac death/other cardiac arrhythmia/seizure/his own stupidity?)...You know you did the right thing -- and the family knows, too, which is probably why they became so irritated! Keep up the good work, Dr. A.

This couple sounds a bit (though not exactly) like my own parents. Maybe I can offer some insight?

This guy's wife brought him in, and he probably didn't want to come in the first place. She may have looked sullen because she wants him to stay, but he won't (though you didn't give us much info about what she said, so I could be wrong.) She won't say a single bad thing about her husband, who has stuck with her through everything and that's been a lot.

They've had some bad experiences with doctors saying authoritative things that turn out to not be true and even cause some damage.

Even at that weight, he may have had low blood sugar. My dad, a rather large man of approximately the same age, was just diagnosed with diabetes. He is insulin resistant, so that even with higher blood sugars he felt/acted like he had low blood sugar. If this guy doesn't eat when he's used to, he probably starts feeling sick. Hence the self diagnosis.

(My dad is very compliant with doctor's advice and is managing it very well, while having lost weight through the course of his diet changing. It was hard, because he did feel sick at what was higher blood sugars in normal people. But he has it down now, and is feeling better than he has in years.)

Another factor may have been finances: they could easily fall through that rather large crack of uninsured (because they are self employed and can't afford it) and can't really afford much more than an office visit (and that's a stretch), but don't qualify for assistance.

If you are getting a middle aged couple like that, try using that 20 minutes to get an idea of what is going on behind the scenes. Maybe it would have been better to talk about how much less expensive a one night stay for testing in the hospital would be over a couple of weeks in the ICU. And how he needs to be healthy for his family.

*blush* i was there once, but I stayed :0.... it was after my second daughter was born, I had only been discharged for a day and they wanted me back in and I didn't have my newborn baby girl with me *snif* Turns out there was fluid in my lungs, from post partum pre-eclimsia... (they didn't know what was wrong at this time, not till i seen my regular doc that monday) I begged to go home the folloing day (sunday night) and they let me only because i had an apt monday.. Yes he ended up sending me back in the hospital for another four days, but this time I had my baby with me;) I didn't argue anymore.

Frustrating patients are a standard annoyance for every doc. We might take a gentle approach, detail our reasoning, explain the necessity of tests and still get stubborn responses. Sometimes cajoling works, often it doesn't. When the patient goes AMA, all we can do is shrug our shoulders and hope that God takes over.

And then one suggestion which you can take or leave as you wish. I totally agree with what you said and did, but did you perhaps recommend that even if the patient wished to leave AMA, that he come see you tomorrow at the office or call and check in? Just to have him know that he has some follow up and doesn't have to fall flat on his face alone once he realizes he was an idiot for not listening to you?

Hang in there.... Now I'm singing along to Daniel Powter's, "You had a bad day..." LOL

huh, i'm sorry that has to happen so much...it seems to me that medical professionals are expected to "produce" a quick, timely solution oftentimes, and at the same time, there are so many of us (patients) that fall through the cracks with financing frustrations! it sounds like you did your best to try to help him, and there is nothing else to do...

That AMA form is a nifty deal - they get to leave and kill themselves via disease process and we can't be sued. Heck, I make people sign the sucker, or else have a nurse witness the conversation, document it and document the AMA dismissal.

You did what you could. I do have to take exception with the low blood sugar/weight comment though. Did anyone check his BgL? I am diabetic, and I am overweight...I can easily have a low simply by over-shooting my insulin needs. And it is damn hard to lose weight and double that when you are a diabetic (especially newly diagnosed) when you are being told you have to eat 6 times a day! Until you learn what you may eat, how much of each thing and portion size, that weight will not budge. And when it does start to come off, it is excruciatingly slow. And let's not even talk about the fact that insulin causes weight gain!

I think sometimes that doctors tell us to take certain number of medication for selling products. On a group I am apart of on www.medsocial.com, we asked how much medication do we really take compared to how much they tell us to take and trust me, it is not the same.

I think everyone in medicine can agree you are always going to run into some tough characters! Trust me during my time as a nurse expert witness I ran into my fair share. Glad to see you kept your head up and did what was best. Sometimes people will get mad at you for doing your job but its important to keep a smile on your face!